When assessing a child after heart surgery to correct Tetralogy of Fallot (TOP) which finding should alert the nurse to suspect a le carat output?

Altered level of consciousness and treaty pulse

Bounding pulses and mottled skin

Capillary refill of 2 seconds and blood pressure of 96/47 mmHg

Extremities warm to the touch and pale skin

Answer and Explanation

The Correct Answer is A

A.Altered level of consciousness and thready pulse.

In a child after heart surgery to correct Tetralogy of Fallot (TOF), a thready pulse and altered level of consciousness can be indicative of poor cardiac output. This may suggest that the heart is not effectively pumping blood to meet the body's needs.

B. Bounding pulses and mottled skin: Bounding pulses and mottled skin are not typical signs of decreased cardiac output. Bounding pulses are often associated with increased cardiac output.

C. Capillary refill of 2 seconds and blood pressure of 96/47 mmHg: A capillary refill of 2 seconds is within the normal range, and a blood pressure of 96/47 mmHg is reasonable for a child. These findings do not necessarily indicate poor cardiac output.

D. Extremities warm to the touch and pale skin: Warm extremities and pale skin are not typical signs of decreased cardiac output. Cold extremities and cyanosis may be more concerning signs.

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Correct Answer is ["A","B","D","E"]

Explanation

A. Fever: Osteomyelitis is often associated with fever as it is an infectious process that can cause an elevated body temperature.

B. Unwillingness to move the affected extremity: Children with osteomyelitis may experience pain and discomfort, leading to a reluctance to move the affected limb.

C. A previous closed fracture of an extremity is not typically a direct assessment finding for osteomyelitis. Osteomyelitis is more commonly associated with infections that can spread to the bone, and a previous fracture may not always be present.

D. Redness and swelling at the site: Osteomyelitis can cause local inflammation, leading to redness and swelling at the affected area.

E. Severe pain: Pain is a common symptom of osteomyelitis, and it can be severe, leading to the child's unwillingness to move the affected extremity.

A. A fontanelle that bulges with crying B. Increased respiratory rate C. A high-pitched cry D. Tachycardia

Correct Answer is A

Explanation

A. A fontanelle that bulges with crying.

Myelomeningocele is a congenital neural tube defect that involves the spinal cord. It is associated with an increased risk of hydrocephalus, which can lead to increased intracranial pressure (ICP). The fontanelle (soft spot) on an infant's head can provide insight into ICP. When an infant with myelomeningocele has an increase in intracranial pressure, the fontanelle may bulge, especially when the infant cries. This is due to the buildup of cerebrospinal fluid within the skull.

B. Increased respiratory rate: While increased intracranial pressure can affect various body systems, an increased respiratory rate is not a specific sign of ICP associated with myelomeningocele.

C. A high-pitched cry: A high-pitched cry is not typically associated with increased intracranial pressure in the context of myelomeningocele. Signs of ICP in infants may include irritability, lethargy, vomiting, and changes in head circumference.

D. Tachycardia: Tachycardia can be a response to stress or discomfort in an infant, but it is not a specific indicator of increased intracranial pressure related to myelomeningocele.

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When assessing a child after heart surgery to correct Tetralogy of Fallot (TOP) which finding should alert the nurse to suspect a le carat output?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which would the nurse assess in a child diagnosed with osteomyelitis? Select all that apply.

Correct Answer is ["A","B","D","E"]

Explanation

The nurse reports to the healthcare provider signs of increased intracranial pressure in an infant with myelomeningocele who has which finding?

Correct Answer is A

Explanation

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